Fatty liver disease, a condition of extra fat buildup in the liver, is a growing problem in North America, affecting 20 to 40% of the adult population. As the disease progresses, it can cause inflammation and damage to the liver. Eventually scar tissue can form (called fibrosis) and, when extensive, it is known as cirrhosis of the liver. Cirrhosis can lead to liver failure and liver cancer…
I always thought that fatty liver and cirrhosis were only caused by drinking too much alcohol. But there are two main forms of fatty liver disease: alcoholic and non-alcoholic. About 5% of the disease is the alcoholic type, caused by heavy drinking. The balance, those with non-alcoholic fatty liver, occurs in people who aren’t heavy drinkers. Although the underlying cause isn’t known for sure, being very overweight, having Type 2 diabetes, or metabolic syndrome (a combination of insulin resistance, high blood pressure, high cholesterol, and/or high triglycerides) are associated with risk. About 1 in 10 children are reported to be affected by non-alcoholic liver disease.
Symptoms of fatty liver disease
Those with fatty liver often have no symptoms until it progresses to cirrhosis of the liver. Symptoms can include abdominal pain or a feeling of fullness in the upper right side of the belly, nausea, loss of appetite, weight loss, yellowish skin and whites of eyes (jaundice), swollen belly and legs (edema), extreme tiredness or mental confusion and weakness.
Because early fatty liver disease often has no symptoms, it is sometimes elevated liver enzymes, found in a routine blood test, that first alert your doctor that something may be wrong (increased liver enzymes in the blood are a sign of liver injury of some kind). An ultrasound or CT scan of the liver may show suspicious changes, but a liver biopsy (a sample of the liver) is the best test to confirm the diagnosis and see how advanced the damage is.
How is fatty liver treated?
There is no specific treatment for fatty liver disease. Instead, the focus is on changing lifestyle to control factors that contribute to the condition, such as:
Avoiding alcohol
Losing weight (even 5 to 10% loss can help)
Controlling diabetes, cholesterol and triglycerides
Taking vitamin E
In some cases, taking certain diabetes medications (thiazolidinediones) can be helpful
What about prevention?
Preventing a disease is always better than trying to cure it, especially when there aren’t good treatments available. Strategies to prevent fatty liver disease are similar to those for any healthy lifestyle. Stay at a healthy weight, exercise regularly, limit alcohol consumption, and treat other health conditions, such as diabetes or metabolic syndrome as recommended by your doctor. Getting regular check-ups can help to detect elevated liver enzymes that are often the first sign of fatty liver disease.
Make sure you aren’t taking medications that can damage the liver or, if you need to take one that does, be sure to monitor liver function as your doctor advises. Note that taking more than the recommended dose of acetaminophen (Tylenol), included in many pain and cold medicines, can cause liver damage.
Hepatitis viruses can also cause liver damage, but vaccines are available for hepatitis A and B. If you are at risk of exposure to either of these viruses, ask your doctor (or pharmacist in some areas) about getting vaccinated.
The liver is amazingly able to heal itself. Avoiding alcohol, changing your diet, or losing extra weight can reverse early liver damage. Fatty liver disease by itself won’t kill you, but it can develop into a more serious problem if it progresses to cirrhosis of the liver that can become liver failure or liver cancer.
The Mediterranean diet, which is high in vegetables, fruit and good fats (like omega-3s) and low in added sugar, is considered an example of a good diet for those diagnosed with or worried about developing fatty liver disease. If you are overweight, it is recommended to lose weight slowly, but steadily, as rapid loss can actually make fatty liver worse.
Although older medical textbooks warn that ketogenic (“keto”) diets can cause liver damage, newer studies that actually measured the effect on fatty liver disease have shown that these diets improve the fat content of the liver, in spite of increasing fats in the blood (which led earlier researchers to wrong conclusions). Studies have shown that the fat content of the diet, even if unrestricted, does not block the beneficial improvement in fatty liver from a diet low enough in carbohydrates to induce production of ketones (“ketogenesis”).
Generally, restriction to less than 20 grams of carbohydrate daily (or up to less than 50 grams, depending on the person) is required to stimulate ketone production. Test strips are available to detect ketones in the urine. Those with diabetes need to avoid dangerously high amounts of ketone production (called ketoacidosis) that can occur when insulin is too low, causing the body to become too acidic. But a diet just low enough in carbs to cause a low level of ketone production is sufficient to improve fatty liver.
Here is a quote from a study (see reference #4 below) on the effects of the keto diet on fatty liver disease (with the "science-ish" terms translated...): “The common belief that increasing dietary fat intake invariably leads to fatty liver and prevents fat mass loss has been recently proven wrong by an elegant experiment, showing that a normocaloric HFKD (normal calorie high fat ketogenic diet) inhibits de novo lipogenesis (new formation of fat) and induces fatty acid oxidation, leading to weight loss and reduced hepatic (liver) fat content. On the contrary, a hypercaloric (high calorie) balanced diet decreases intrahepatic fatty acid oxidation (oxidation of fats in the liver) and increases de novo lipogenesis (new formation of fat) primarily from carbohydrate, and not lipid (fat) substrates, leading to non-alcoholic fatty liver disease (NAFLD) development.” These researchers are telling us it’s the carbohydrates from sugar and white flour in our diet, not the fats, that create fat deposits in the liver and fatty liver disease!
So, besides cutting out added sugar and staying away from anything made with flour (which can be tough to do), how can you get the benefits of a mild ketone-producing diet? Well, I’m a big fan of substitution! Although I’ve always been leery of sugar substitutes, the newer ones use more natural substances that taste sweet but don’t have the carbohydrates of regular sugar. Erythritol, monk fruit and stevia (from the leaf of the stevia plant) are three I know about, that seem better than older sweeteners, like saccharin and cyclamates that were suspected of increasing risk of cancer. Almond and coconut flour can be used to make almost carb-free substitutes for bread, cake and muffins, and there are tons of recipes for keto-friendly desserts and snacks on the internet now. All you have to do is search for something that looks tasty!
But the best way to lower your carbohydrate intake, is to adjust your taste to less-sweet foods. I’ve found that, as I gradually reduce the amount of sugar I add to my food, I have started to prefer my food (even desserts!) to be less sweet, just as my taste adjusted to less salty food when we cut back on salt years ago. It’s interesting what “creatures of habit” we are, even in our taste preferences…
So, could beer (regular or non-alcoholic) be good for fatty liver disease?
It’s well established that heavy drinking can cause damage to the liver, but what about moderate amounts? And is any type of alcohol better than others?
There seems to be a debate over whether low to moderate drinking can contribute to fatty liver disease, with some researchers advising that no amount of alcohol is safe, while other studies suggest that moderate drinking (2 or less drinks per day) may be better than drinking no alcohol at all.
Part of the problem with the studies may be that only one factor (the alcohol) is being tracked, while we know that diets are complex and vary greatly from person to person and culture to culture. For example, if you substitute a sugary drink, like pop or juice, for an alcoholic one, you could be increasing added sugar enough to cause more fats to be stored in the liver, leading to fatty liver disease.
An interesting study done in mice suggests that the hops in beer may have a protective effect on the liver. When they dosed mice with pure alcohol (ethanol), beer with hops, and beer without hops (in equal amounts of alcohol), those who received the beer containing hops had significantly less fat deposited in their livers. This has led to the suggestion that dealcoholized beer with hops might be a good choice for people with fatty liver disease—both to cut back on alcohol consumption (for heavier drinkers) and to benefit from the possible liver protection hops might provide. Of course, we need to keep in mind that the study tested mice not humans. Note that hops give beer its bitter taste—a more bitter beer will contain higher amounts of hops.
Bitter beer has never been a favourite for me, but perhaps my taste can adjust to that too! Since 1/4 to 1/3 of us (statistically) have at least the beginnings of fatty liver disease, it’s something worthy of our attention. Here is a fun article on “10 Brilliant Benefits of Non-alcoholic Beer”, from having fewer calories to being a great choice when you’re the designated driver. Newer non-alcoholic beers have great taste--they're real beer that has had the alcohol removed before bottling!
So, this was an interesting adventure down a complex rabbit hole, that started with a message from a regular reader! I love the ongoing communication I have with my subscribers, so drop me a note if you see something interesting or confusing, have a question you’d like answered or just want to make a comment on what I’ve written…
References:
1. Fatty liver disease: What it is and what to do about it – Harvard Health Publishing
2. Type and Pattern of Alcohol Consumption is Associated With Liver Fibrosis in Patients With Non-alcoholic Fatty Liver Disease -- The American Journal of Gastroenterology
3. Effect of a ketogenic diet on hepatic steatosis and hepatic mitochondrial metabolism in nonalcoholic fatty liver disease -- Proceedings of the National Academy of Sciences of the United States of America
4. Beneficial effects of the ketogenic diet on nonalcoholic fatty liver disease: A comprehensive review of the literature – Wiley Online Library
5. Hops (Humulus lupulus) Content in Beer Modulates Effects of Beer on the Liver After Acute Ingestion in Female Mice -- Journal of Alcohol and Alcoholism
6. Fatty Liver Disease – Cleveland Clinic
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